Incidence and Prevalence

The incidence of a disorder or condition refers to the number of new cases identified in a specified time period. Prevalence refers to the number of individuals who are living with the disorder or condition in a given time period. According to the Centers for Disease Control and Prevention (2021) Early Hearing Detection and Intervention (EHDI) program data from 2019, the prevalence of hearing loss is 1.7 per 1,000 newborns screened. Although 61.7% of those infants are enrolled in early intervention services, there is no available estimate of how many children receive hearing aids. Data from the MarkeTrak IX survey of 17,000 households indicate that approximately 3% of children under the age of 18 years experience hearing difficulties and that approximately 1% have a hearing aid (Abrams & Kihm, 2015). The early identification of hearing loss has been shown to improve access to amplification devices. Within 5 years of enacting universal newborn hearing screening initiatives, 68% of children who had been identified with hearing loss were fitted with hearing aids by 6 months of age, up from 14% before the legislation was enacted (Halpin et al., 2010).

Roles and Responsibilities of Audiologists

Audiologists play a central role in the screening, assessment, diagnosis, management, and treatment of children who are deaf and hard of hearing, including those who use hearing aids. The professional roles and activities in audiology include clinical and educational services (diagnosis, assessment, planning, counseling, and treatment); prevention and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Audiology (ASHA, 2018).

Appropriate roles for audiologists include the following:

• Maintaining knowledge of anatomy, physiology, and pathophysiology of the auditory and balance systems.
• Remaining informed of research in the area of amplification and helping to advance the knowledge base related to hearing aids.
• Remaining current on new technology (e.g., devices, applications) and accommodations designed to facilitate access to classroom instruction for students with hearing aids.
• Educating other professionals about the signs, symptoms, and impact of hearing loss; the specific needs of children using hearing aids; and the role of audiologists in the fitting and management of hearing aids.
• Serving as an integral member of an interprofessional and collaborative team working with children who are deaf and hard of hearing, those who are using hearing aids or hearing assistive technology systems, and their families/caregivers.
• Conducting a comprehensive assessment of hearing, auditory function, balance, and related systems.
• Diagnosing the presence of hearing loss, describing the nature of hearing (and related) disorders, and determining the need and candidacy for amplification and assistive technology.
• Coordinating and conducting a comprehensive, culturally and linguistically appropriate assessment for determination of hearing aid candidacy.
• Administering and interpreting tests to differentiate hearing loss from other auditory disorders (e.g., central auditory processing disorder).
• Referring to appropriate professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services.
• Collaborating with an interprofessional team to develop and implement an appropriate, comprehensive, and person- and family-centered audiologic (re)habilitative management plan.
• Making referrals for educational support through local school districts (e.g., for services and regular assessments provided by a teacher of the deaf, a speech-language pathologist [SLP], and/or an educational audiologist).
• Counseling children who are deaf and hard of hearing and their families on a variety of issues, including self-advocacy strategies and rights to educational and other community services.
• Providing education, support, and resources for understanding communication milestones and risk factors as well as increasing awareness about various language and communication modalities.
• Providing recommendations for the selection, fitting, and dispensing of ear-level amplification (i.e., hearing aids).
• Fitting and maintaining amplification and other sensory devices and assistive technology for optimal use.
• Educating children and their families about the proper use and care of hearing aids.
• Validating hearing technology use in a variety of communicative settings through interprofessional communication.
• Conducting ongoing evaluation and modification of the audiologic management plan.
• Providing prevention information and education (e.g., on noise-induced hearing loss), promoting hearing wellness, and monitoring the acoustic environment.
• Providing consultation regarding accessibility for children using hearing aids in public and private buildings and in relation to program participation and service provision.
• Advocating for the communication needs of all children, including advocating for the rights and funding of services for children who are deaf and hard of hearing.

As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists who serve this population should be specifically educated and appropriately trained to do so. The Joint Committee on Infant Hearing (JCIH, 2019) notes that “audiologic diagnosis of the infant is the sole purview of the audiologist with specific skills, knowledge, and access to all necessary equipment for infant and early childhood audiologic diagnostic evaluations” (p. 12).

Roles and Responsibilities of Speech-Language Pathologists

SLPs play a role in the identification, screening, assessment, and (re)habilitation of children who are deaf and hard of hearing, including those who use hearing aids. Professional roles and activities in speech-language pathology include clinical and educational services; prevention and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles and responsibilities for SLPs include the following:

• Maintaining general knowledge of anatomy, physiology, and pathophysiology of the auditory and balance systems and the effects of hearing loss on communication development.
• Maintaining general knowledge of amplification devices and hearing assistive technology systems.
• Maintaining general knowledge of hearing aid parts and their function/maintenance (e.g., battery insertion, settings).
• Remaining current on technology and accommodations designed to facilitate access to classroom instruction for students with hearing aids.
• Educating other professionals about the signs, symptoms, and impact of hearing loss as well as the specific needs of children using hearing aids.
• Referring to an audiologist for comprehensive hearing health care.
• Serving as an integral member of an interprofessional and collaborative team working with children who are deaf and hard of hearing, those who are using hearing aids and/or hearing assistive technology systems, and their families/caregivers.
• Providing a direct comprehensive, culturally and linguistically appropriate evaluation of speech, language, cognitive, communication, and social skills in the child’s current and/or preferred modality.
• Referring to other professionals and organizations to facilitate access to comprehensive services.
• Collaborating with an interprofessional team to develop and implement an appropriate, comprehensive, and person- and family-centered aural (re)habilitation and/or speech-language intervention plan, including referral to audiology with any concerns about hearing status (e.g., changes in status).
• Performing routine visual inspection and listening checks of the hearing aids for purposes of troubleshooting (e.g., battery check, behavioral listening check).
• Counseling children who are deaf and hard of hearing and their families on a variety of issues, including self-advocacy strategies and rights to educational and other community services.
• Providing education, support, and resources for understanding communication milestones and risk factors as well as increasing awareness about various language and communication modalities.
• Monitoring communication competence in a variety of settings using data and functional outcome measures.
• Providing consultation regarding accessibility for children using hearing aids in public and private buildings and in relation to program participation and service provision.
• Advocating for the communication needs of all children, including advocating for the rights and funding for services for children who are deaf and hard of hearing.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Collaboration With Other Professionals

A child- and family-centered plan of care for a child using hearing aids will involve a team of professionals. The composition of an interprofessional team will vary based on the needs of the child and their family. These professionals may include, but not be limited to, the following:

• audiologist (i.e., clinical audiologist, educational audiologist)
• aural (re)habilitation specialist
• classroom teacher
• counselor
• developmental pediatrician
• early interventionist
• family practice physician
• genetic counselor
• occupational therapist
• ophthalmologist
• otolaryngologist
• pediatrician
• psychologist
• physical therapist
• social worker
• SLP
• teacher of the deaf and hard of hearing

For example, some children may have executive function needs, whereas others may have needs around the fine motor manipulation of hearing aids, and yet others may have sensory adjustment needs around promoting the consistent wearing and use of hearing aids. See the ASHA resource on interprofessional education/interprofessional practice (IPE/IPP) for more information on this topic.

Counseling

Counseling and education for a child who is deaf or hard of hearing and their family begins during the initial contact with an audiologist. Along with providing information on the overarching topics of hearing loss and amplification, the audiologist can offer guidance and support in the decision-making process of the child and family regarding potential hearing aid implementation, selection, and use. Counseling will continue throughout the entire hearing aid fitting (as appropriate and if selected) and follow-up process. Information, education, resources, and answers to questions should be provided in a manner that is understandable to the child and/or their family and in their heritage language. See the ASHA resource on health literacy for more information.

Topics and issues addressed through counseling may include

• the impact of hearing loss on child development,
• communication modalities,
• coping and compensatory strategies,
• identification and response to barriers to effective implementation of hearing aid use,
• general hearing aid use and care,
• adjustment to hearing aids, and
• realistic expectations for treatment.

As a member of an interprofessional care team, the SLP also plays a key role in counseling the child and/or family regarding communication needs and the effects of hearing loss on child development. Referrals for formal counseling by a mental health provider (e.g., school counselor, psychologist) may also be indicated.

The Ida Institute offers tools specifically designed for counseling children and families (e.g., My Hearing Explained for Children). ASHA’s Patient Education Handouts—Audiology Information Series offers various handouts that may be helpful during child and family counseling activities. For more information on this topic, visit the ASHA Practice Portal pages on Counseling For Professional Service Delivery and Cultural Responsiveness.

Assessment

Prior to the hearing-aid-fitting process, comprehensive assessment(s) are completed. A comprehensive assessment will determine the type, degree, and configuration of the hearing loss. It will describe the child’s current developmental functioning in comparison to their expected milestones, communication needs, and possible aural (re)habilitation needs. Potential candidacy for amplification will be established, and baseline measures for future monitoring will be obtained.

Components of a comprehensive assessment may include, but not be limited to,

• case history,
• comprehensive audiologic assessment,
• speech-language assessment,
• medical referral for medical assessment, and
• candidacy and needs assessment.

Case History

A thorough case history may include, but not be limited to, the following:

• child’s age
• hearing health history (including onset of hearing loss)
• prenatal and birth history
• medical history (including current medications and medication history)
• developmental milestone information
• family history of hearing loss
• results of genetic testing
• coexisting disabilities
• current communication status and needs (including current and preferred language/communication system)
• current educational status and services
• child and/or family goals and expectations (including responses to questionnaires and/or self-assessment tools regarding communication and quality of life)
• information about support systems

Comprehensive Audiologic Assessment

An audiologic assessment of both ears is performed to determine the type, degree, and configuration of hearing loss and to gather information (specific to each ear) that is needed for the initiation of amplification device fitting. A comprehensive audiologic assessment will include otoscopy as well as a test battery individualized to the child (i.e., based on age and developmental screening). The test battery may include, but not be limited to, the following:

• acoustic immittance testing
• auditory brainstem response (ABR)
• distortion product and/or transient evoked otoacoustic emissions (DPOAE/TEOAE)
• pure-tone testing (including air- and bone-conduction measures)
• speech audiometry

See the Assessment section of the ASHA Practice Portal page on Hearing Loss in Children for details on audiologic assessment components.

Early Intervention Referral

When a child under the age of 3 years is identified as having a hearing loss, a referral to the child’s state early intervention program is required as soon as possible and within 7 days of the identification (Early Intervention Program for Infants and Toddlers With Disabilities, 2011). Children diagnosed in infancy should begin receiving early intervention services by 6 months of age (JCIH, 2019). For details on the latest JCIH position statement, see the JCIH website. The National Center for Hearing Assessment and Management (NCHAM) provides information on Early Hearing Detection and Intervention (EHDI) programs in each state. More information is available on the ASHA Practice Portal pages on Early Intervention and Newborn Hearing Screening.

Speech-Language Assessment

A speech-language assessment for a child who is deaf or hard of hearing is completed to obtain information regarding that child’s current communication and language status, to identify areas of concern for the child and/or family, to determine specific intervention needs, and to refer the child and their family to other appropriate professionals (e.g., medical, clinical, educational) in order to facilitate access to comprehensive services.

A comprehensive assessment will be guided by information provided by the child, the child’s family, teachers, and/or additional caregivers. The assessment may include formal and/or informal measures of speech, language, cognitive skills, executive function, social skills, auditory skills, speech perception, and functional listening skills. It will be completed with consideration to the child’s language(s) and communication modalities (e.g., spoken language, signed language, sign-supported spoken language, total communication, augmentative and alternative communication), the impact of any current hearing device and hearing assistive technology, and the child’s current developmental abilities.

Assessment may include, but not be limited to, the following:

• articulation and phonology
• auditory skill development (i.e., detection, discrimination, recognition, comprehension)
• cognition, including executive function skills
• functional listening and communication skills
• language comprehension and production, including reading and writing
• oral motor structure and function
• prelinguistic skills (e.g., vocal development)
• social communication
• voice quality and prosody

Speech, language, auditory, and cognitive-communication skills are assessed on an ongoing basis and in a variety of settings, particularly when changes in hearing status, hearing aids, or hearing assistive technology occur. Any concerns about a change in a child’s hearing function or lack of auditory development warrant a referral back to an audiologist. See the ASHA Practice Portal page on Language and Communication of Deaf and Hard of Hearing Children for more information. 

Medical Referral

The timing and precipitating factors of the identification and reporting of a hearing loss or suspected hearing loss impact the establishment of a child’s medical home in relation to hearing health care. For example, a child may be identified through a newborn hearing screening program, a failed hearing screening at school, or parent concern. A pediatrician or a family physician may be the first medical professional involved in the child’s hearing health care. Referrals to an audiologist, an otolaryngologist, and other specialists (e.g., ophthalmologist, geneticist, neurologist) are based on the child’s specific needs, concerns, and/or signs and symptoms. Specialists can help determine the etiology of the hearing problems and identify related conditions. See the American Academy of Pediatrics Early Hearing Detection & Intervention Implementation Tip Sheet [PDF] for examples of tools (i.e., checklists, screening algorithms) to support medical home providers in monitoring a child’s hearing, making appropriate referrals, and collaborating with pediatric specialists—including audiologists and SLPs.

For an individual under 18 years of age, medical clearance must be obtained from a physician (preferably one who specializes in childhood hearing loss) prior to being fit with amplification (i.e., hearing aids). Medical clearance must occur within the 6 months prior to the hearing aid fitting per the Code of Federal Regulations (21 C.F.R. § 801.421; Hearing Aid Devices; Conditions for Sale, 2020). Neither the parents nor the child can waive this requirement. See the Code of Federal Regulations (21 C.F.R. § 801.420; Hearing Aid Devices; Professional and Patient Labeling, 2020) and the U.S. Food and Drug Administration’s How to get Hearing Aids for more information on this topic.

Candidacy/Needs Assessment

A needs assessment is conducted, in part, to determine hearing aid candidacy and to develop child- and family-centered goals. Along with assessing the impact of a hearing loss on everyday listening situations, the needs assessment gathers information regarding each child’s unique circumstances. The needs assessment can help affirm the need for treatment, identify the need for additional referrals, and establish realistic expectations.

In addition to auditory and communication function, a variety of factors may impact an individual’s candidacy for, and choices regarding, hearing aids. Factors may be cultural, sociological, environmental, physical (e.g., craniofacial, visual, manual), and/or psychological.

A needs assessment for hearing aid candidacy may include various speech perception measures (e.g., speech awareness/reception threshold, Ling 6-Sound Test for detection, speech recognition). Speech perception measures can be administered without the use of a hearing aid at varying levels of stimuli complexity and in quiet and noise to establish a baseline prior to treatment. Calibrated and recorded stimuli are often used, when possible, because monitored live voice may under- or overpredict the child’s abilities.

An individual ear canal acoustics assessment (e.g., measure of the real-ear-to-coupler difference [RECD]) may be included to assist with determining a child’s unaided speech intelligibility index score and potential candidacy for hearing aids (McCreery et al., 2020).

Self-assessments can be used as measures of self-perceived communication needs, and the results may be helpful in establishing goals and expectations for amplification. When a child is too young to complete a self-assessment, similar questionnaires may be completed by a child’s parent, caregiver, or teacher. Results of self-assessments and/or parent and caregiver questionnaires are beneficial to the planning, implementation, and evaluation of any audiologic intervention program. Examples of tools that may be helpful to this process can be found at Ida Institute: Tools and at The University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP) site.

Additional Considerations

Multilingual Speakers

When evaluating and fitting hearing aids for multilingual children, implications around the child’s phonetic inventory, phonology, and syntax should be considered. Using only English words to evaluate multilingual listeners may lead to faulty clinical impressions. Evaluating multilingual speakers in their primary or dominant language will give the most accurate picture of their speech recognition ability. Specific recommendations on how to program a hearing aid for many non-English languages have been offered (Chasin, 2011).

Sign Language Users

Some children who are deaf and hard of hearing use sign language as their primary language. Achieving spoken language may not be among their goals for amplification. Other goals, such as alerting to environmental sounds and improving personal safety, may be the priority when fitting hearing aids for these children. Collaboration with qualified sign language interpreters in appropriate situations is essential.

See the ASHA Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators for more information.

Treatment Planning

A child- and family-centered audiologic treatment plan will reflect the child’s individual needs, language and communication goals, and developmental level. Specific services may be influenced by the following:

• the child’s age
• age at onset of the hearing loss
• age at which the hearing loss was confirmed
• etiology of the hearing loss
• type, degree, and configuration of the hearing loss
• unaided speech intelligibility index
• age at which amplification is introduced
• language(s) and communication approach(es) that the child is using (e.g., listening and spoken language, signed language, sign-supported spoken language, cued speech, augmentative and alternative communication)

The audiologist and/or SLP will provide comprehensive assessment results, findings, and recommendations to the child and/or family (as appropriate per age and developmental level) in a format that is understandable and that allows for full participation in joint decision making in all areas of the proposed treatment plan. See ASHA’s resource on health literacy for more information.

Hearing aid(s) may be recommended as one part of a larger management program. Treatment planning may include, but not be limited to, the following:

• education for children and their families regarding hearing aid parts, when and how to wear the hearing aid, how to identify when the hearing aid is not working properly, and how to troubleshoot problems with the hearing aid
• information and resources regarding device retention
• identification and support of realistic expectations for amplification
• discussion of hearing assistive technology systems and school accommodations
• discussion of aural (re)habilitation, early intervention, and/or educational services and options
• referrals to other professionals, as indicated
• decisions on when and how outcomes of amplification will be measured and who will be involved (e.g., parent, child, teacher)
• recommendations and setting of treatment time frames, including long-term follow-up

International Classification of Functioning, Disability and Health

The World Health Organization (2001) published the International Classification of Functioning, Disability and Health (ICF) as a classification of health and disability based upon functional status. This classification system can be used to assist clinicians in establishing goals and in determining specific outcomes that can be measured through client report.

See the ASHA page on International Classification of Functioning, Disability, and Health (ICF) for more information.

Hearing Aid Selection

Appropriate hearing aid device and feature selection is an ongoing process and can change as a child grows and as their listening needs evolve. A hearing aid is selected based on key information such as the following:

• type, degree, and configuration of the hearing loss
• child’s age and developmental status
• anatomy of the ear and craniofacial characteristics
• medical conditions of the ear
• dexterity
• communication needs and goals
• unaided speech intelligibility index
• connectivity needs (e.g., compatibility with assistive technology)

Examples of hearing aid types that may be selected for children include the following, with some types being more appropriate for older children and teenagers:

• Behind-the-ear hearing aid (BTE): The hearing aid hooks over the top of the child’s ear and rests behind the ear. A tube connects the hearing aid to a custom earmold, which is replaced as the child’s ear grows. This is the most common type of hearing aid used by children.
• Receiver-in-canal hearing aid (RIC) or receiver-in-the-ear hearing aid (RITE): The hearing aid hooks over the top of the child’s ear and rests behind the ear. A thin wire connects the hearing aid with the speaker or receiver, which sits in the ear canal.
• Custom in-the-ear hearing aid (ITE): The hearing aid sits in the ear canal. It can vary in size, from the smallest being completely in the canal to the largest being a full shell in the ear, which fills most of the bowl-shaped area of the outer ear.
• Bone conduction sound processor: The sound processor typically sits on or connects to the skull in the temporal bone area. It can vary in size and retention method. Some bone conduction devices are connected via headbands, some are surgically implanted and connected with an abutment, and some are attached with a medical adhesive. Regardless of retention, a bone conduction sound processor transfers sound by vibration directly to the cochlea, bypassing abnormalities in the external and middle ear.
• Contralateral routing of signal hearing aid (CROS): The transmitter (with microphone) picks up sound from the unaidable ear and transmits it to the receiver in the ear with typical hearing. This may be considered as an option for children with single-sided deafness. It is available in BTE, RIC, RITE, and custom versions.
• Bilateral contralateral routing of signal hearing aid (BiCROS): The transmitter (with microphone) picks up sound from the unaidable ear and transmits it to a hearing aid worn on the ear with aidable hearing. The hearing aid worn on the aidable ear serves two purposes: It receives the signal and amplifies the sound transmitted from the unaidable ear while also providing needed amplification for the aidable ear. This may be considered for a child with asymmetrical bilateral hearing loss.

Hearing Aid Features

The following hearing aid features are important to consider when selecting a hearing aid for a child:

• Battery type: The ability for the hearing aid to be rechargeable versus using standard batteries can be an important consideration for some families and children.
• Connectivity: The ability for the hearing aid to connect to other devices (e.g., smartphones, tablets, computers, televisions) can be an important factor contributing to sustained device use and access to devices that deliver sound for both educational and quality-of-life purposes.
• Data logging: The ability for the hearing aid to track wear time is important for counseling purposes, determining a child’s success with hearing aids, and facilitating discussions about potential barriers to hearing aid use.
• Digital noise reduction: The implementation of signal-processing strategies aimed at reducing gain in response to background noise may provide better comfort of listening. It is important to verify that the speech signal is not compromised when speech and noise are presented at the same time.
• Directional or omnidirectional microphones: Directional microphones benefit children who are of school age and older. For infants and very young children, omnidirectional microphones provide the opportunity for incidental learning. The type of microphones used are selected based on a child’s age and listening needs.
• Earmold venting: Venting provides pressure equalization between the ear canal and the environment. For infants or children with very small ear canals, earmold venting may not be possible. The vent size will be determined based upon factors specific to the child and their hearing loss. Venting provides options to meet the acoustical needs of difficult-to-fit configurations of hearing loss (e.g., steeply sloping and/or reverse sloping).
• Feedback management: With a child’s rapidly growing ear, acoustic feedback can be a challenge. It is important to obtain an appropriate seal for the earmold in relation to the child’s ear size and to check for any acoustic feedback. If the audiologist chooses to activate the feedback management feature on the hearing aid, it is important to verify that this is not affecting high-frequency gain.
• Remote microphone compatibility: The ability for the hearing aid to connect to a frequency modulation (FM) and/or a digital modulation (DM) system allows for increasing the signal-to-noise ratio and providing direct audio input. The audiologist can check with a child’s school district to see what type of hearing assistive technology their school uses.
• Frequency lowering: Frequency-lowering technology makes high-frequency sounds (e.g., speech sounds) available at lower frequencies where the degree of hearing loss may be less. This feature may be especially useful for a child with severe sloping sensorineural hearing loss in the high frequencies.
• Remote device programming: The ability for a child and/or parent to interface with an audiologist remotely (i.e., via telehealth) to make necessary adjustments may be an important feature for sustaining hearing aid use.
• Retention: Hearing aid retainers, such as clips, headbands, and specialty tape, can be helpful in keeping hearing aids on a child and avoiding hearing aid loss.
• Safety: Tamper-resistant battery doors and protective covers for participation in sports and water activities may be important considerations.
• Smart applications: The ability for the child and/or parent to be able to control the hearing aids and/or access information about the hearing aid through applications can be helpful.
• Wireless binaural synchronization: The ability for each hearing aid—assuming that the child is using two hearing aids—to receive and share auditory information between one another is an important consideration. Benefits of binaural synchronization may include easier manual control of hearing aids, appropriate automatic gain enhancement or reduction, appropriate activation of noise reduction systems, and possible improvements in localization and hearing in background noise.

Hearing Aid Fitting, Verification, and Validation

Once a hearing aid has been selected and received, the in-depth process of fitting, verification, and validation begins. The verification and validation processes ensure optimal use of the hearing aid so that the user can derive maximum benefit from the hearing aid and its features. It is beneficial for the child and family members to be highly involved and for the audiologist to continue offering education and counseling as appropriate (e.g., discussions of realistic expectations for progress with hearing aids).

When fitting hearing aids for children, speech audibility is a primary focus. The child’s age and listening behaviors impact the verification process, especially when considering the use of advanced features (McCreery, 2011).

Quality Control

Upon receipt of the device(s), the audiologist does a visual inspection, looking for any defects (e.g., cracks on the earmold). They also conduct a listening check to rule out excessive circuit noise and intermittency.

Electroacoustic Analysis (Test Box)

Prior to placing the hearing aid on the child’s ear, electroacoustic measurements should be performed according to ANSI S3.22-2014 (American National Standards Institute [ANSI], 2014, or the current standard) to determine whether the hearing aid meets its intended performance measures in the text box. Coupler measures of gain, frequency response, maximum output, distortion, and battery drain should conform to the manufacturer’s published specifications and prescriptive fitting algorithms appropriate for children. If the electroacoustic performance does not meet expected performance measures, replacement by the manufacturer is advised.

Physical Fit

The audiologist determines the physical fit of the hearing aid and earmold (if applicable) by assessing physical comfort, absence of feedback, ease of insertion and removal, and security of fit. If needed, fit can be adjusted by remaking, altering, or exchanging the hearing aids and/or earmolds. Infants and young children grow quickly and require frequent replacement of their earmolds, as often as every 1–2 months during the first year of life. The audiologist also determines the need for any hearing aid retainers (e.g., hearing aid clips, specialty tape).

Fitting Approaches

Desired Sensation Level (DSL) version 5.0 (Scollie et al., 2005; Seewald et al., 2005) and NAL-NL2 from the National Acoustic Laboratories (Keidser et al., 2011) are commonly used prescriptive fitting algorithms for children. Both prescriptions seek to optimize speech intelligibility while maintaining patient comfort with loudness level. The prescriptive formulas offer an initial starting point for the fitting process. Fine tuning may be required after the verification process to ensure optimal fit.

Real-Ear Measures

Real-ear measures are used to verify prescriptive fitting targets and various hearing aid features. The audiologist can measure the actual sound delivered by a distinct hearing aid to a specific child, thus allowing for an accurate fitting. Real-ear measurements are completed using probe tubes placed into the ear canals and can be done with or without the hearing aid in place. Real-ear measures have been described in detail by Mueller (2001). More information can also be found on the ASHA Practice Portal page on Hearing Aids For Adults.

Some older children can tolerate the completion of probe microphone measures with the use of prescriptive targets. For babies, younger children, and those who otherwise cannot tolerate probe microphone measurements, real-ear-to-coupler difference (RECD) measurement can be used to verify hearing aid benefit (McCreery, 2013; McCreery & Walker, 2017). To do this, the audiologist takes a probe microphone measure with just the child’s earmold or with an insert in the child’s ear. Once that information is collected, the hearing aid can then be tested in a separate test box and adjusted accordingly. See RECD Measurements for more information.

Other measurements and verifications may include the maximum output level of the hearing aid and the audibility of speech for various speech volume levels: soft, average, and loud. If a child has a sloping hearing loss, aided frequency responses using high-frequency sounds, such as the /s/ and /ʃ/ phonemes, should be obtained to assess whether frequency-lowering technology is required to achieve audibility of these sounds (Scollie et al., 2016).

Speech Perception Measures

Aided speech perception testing assists in the validation of hearing aid benefit. It can be completed at various input levels in quiet and in noise to help guide changes to hearing aid programming or in the overall plan of care. Information from speech perception testing and relevant questionnaires (e.g., auditory development, auditory performance) can be shared with the child’s SLP and/or teacher of the deaf to help determine the relative impact of speech perception issues versus speech production difficulties and to guide therapy goals.

Questionnaires and Self-Report Tools

Child and/or family feedback is necessary for validation of optimal hearing aid use and benefit. A variety of questionnaires and self-report tools can be used in this process. See UWO PedAMP for examples.

Aural and Communication (Re)habilitation

Aural (re)habilitation can be defined as “an ecological, interactive process that facilitates one’s ability to minimize or prevent the limitations and restrictions that auditory dysfunctions can impose on well-being and communication, including interpersonal, psychosocial, educational, and vocational functioning” (ASHA, 2001, p. 4). Habilitative services refer to those services focused on attaining listening, language, and communication skills that have yet to be acquired (e.g., in the case of a child who is identified with hearing loss prelingually). Rehabilitative services refer to those services focused on maintaining, reestablishing, and/or improving current listening, language, and communication skills. The aural (re)habilitative process is designed to be interactive, individualized, and child- and family-centered. The roles of audiologists and SLPs in the provision of (re)habilitation services for children using hearing aids may be complementary, interrelated, and, at times, overlapping.

An aural and communication (re)habilitation plan may include, but not be limited to, the following types of intervention. See the ASHA Practice Portal page on Language and Communication of Deaf and Hard of Hearing Children for more information.

Child and Family Counseling

Child and family counseling is designed to include

• participation from the child, their family and caregivers, and other professionals working with the child (e.g., classroom teachers, teachers of the deaf);
• proactive assessment and management of potential barriers to hearing aid use (e.g., comfort or retention issues);
• discussion of self-advocacy (e.g., rights to services, funding of services);
• recommendations for support groups and community resources, as indicated;
• education on the full spectrum of language, communication, and educational approaches used by children with hearing aids; and
• training for communication partners.

Education on Technology

Education on the specifics of hearing technology may include participation from the child, their family and caregivers, and other professionals working with the child. Topics covered may include

• orientation to hearing aid function and parts;
• training on hearing aid use, care, and management;
• training on maximizing connectivity technology based on the child’s communication needs and goals; and
• training on how to complete daily functional listening checks, visual inspection, troubleshooting, and data logging with the goal of maximizing consistent use.

Hearing Assistive Technology Systems

Hearing aids provide children access to their auditory environments. However, listening can still be challenging (even when using hearing aids) with added background noise, reverberation, and distance from the speaker. Hearing assistive technology systems can help children receive better access to sound and speech in challenging environments.

Personal frequency modulation (FM) or digital modulation (DM) systems transmit speech signals directly from the speaker (through a microphone) to the child’s hearing aids. Personal FM and DM systems are frequently used in the school setting but may also provide benefit outside of school (e.g., in the car, in crowded places) and for young children not yet in school. Sound-field systems amplify the speaker’s voice over the background noise for everyone in the room.

As with hearing aids themselves, it is important that any hearing assistive technology system used by a child go through a verification process to ensure that it is working properly and is being used for maximum benefit. Clinical audiologists and educational audiologists can collaborate to ensure that any technology used by the child meets their needs both in and out of the classroom setting. For more information on this topic, see the ASHA resource on hearing assistive technology systems for children and visit the following two resources by Supporting Success For Children with Hearing Loss:

• FM Systems
• Personal FM vs Sound Field FM

Environmental Modifications

Providing strategies to adjust a child’s environment (e.g., home, child care, school, community settings) to maximize effective communication interactions may also be essential. Methods for modifying the environment for optimal communication may include

• choosing strategic seating arrangements;
• improving room acoustics and minimizing background noise;
• adjusting lighting to enhance visual cues;
• providing access to speech-to-text services (e.g., closed captioning); and/or
• installing visual, amplified, and/or vibrotactile alerting systems.

Direct Intervention

A child’s audiologist(s) and/or SLP will develop an individualized intervention plan that is specific to their needs and goals. The plan will be developed based on continued child and family participation—with consideration given to the communication systems and language(s) used by the child and their family, and in consultation with other members of the child’s care team (e.g., teacher of the deaf, occupational therapist). Components of an individualized plan may include, but not be limited to, the following:

• auditory training (e.g., listening skill development) and/or visual cueing to target speech perception, functional listening skills, and understanding of speech and language
• cognitive-communication skills and strategies training to target social interaction, self-advocacy skills, executive functioning, and conversational strategies
• speech and/or language development to target articulation, voice, expressive and receptive language, and/or literacy skills across applicable languages and communication modalities (e.g., spoken, signed, written)

Goals and interventions may change as the child’s skills and needs evolve and/or as the family identifies different priorities.

(Ongoing) Validation and Outcomes Measurement

A child’s progress with and benefit from hearing aids may be measured in several ways and may require documentation by more than one professional (e.g., audiologist and SLP). Outcome measures are developed in a child- and family-centered manner. Outcomes may be tied to the ICF framework and may include measures related to

• functional listening skills,
• clarity of speech,
• use of communication and self-advocacy strategies in daily activities, and
• quality of life.

Outcomes, treatment benefit, and overall progress may be documented using questionnaires (McCreery & Walker, 2017), speech perception measures, and/or a periodic review of functional goals.

Educational Services

Children who are deaf and hard of hearing can qualify for educational services in a variety of ways. A child may have an individualized family service plan (IFSP), an individualized education program (IEP), or a Section 504 plan. ASHA’s resource on eligibility and dismissal in schools provides more information and resources.

Children under 3 years of age must be referred to the state Early Hearing Detection and Intervention (EHDI) program and the Early Intervention Program for Infants and Toddlers with Disabilities as soon as a hearing loss has been identified. Educational services for children ages birth to 3 are typically home based and often include a parent-coaching model. Any child who is older than 3 years of age is referred to their local area school system’s special education program.

Both modifications (e.g., altered curriculum) and accommodations (e.g., classroom acoustics, strategic seating) are important considerations when defining service plans for children who are deaf and hard of hearing.

Reimbursement

ASHA’s resources on the following topics provide information on billing, reimbursement, and related issues regarding hearing aids:

• billing and reimbursement
• insurance and hearing aids
• practice considerations for dispensing audiologists
• state insurance mandates for hearing aids

ASHA Resources

• ASHA State-by-State
• Billing and Reimbursement
• Child Audiologic (Hearing) Habilitation
• Eligibility and Dismissal in Schools
• Health Literacy
• Hearing Assistive Technology
• Hearing Assistive Technology Systems (HATS) for Children
• Hearing-Related Topics: Terminology Guidance
• IDEA Part B: Individualized Education Programs and Eligibility for Services
• IDEA Part C: Individualized Family Service Plan
• Infection Control Resources for Audiologists and Speech-Language Pathologists
• International Classification of Functioning, Disability, and Health (ICF)
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• Insurance and Hearing Aids
• Patient Education Handouts—Audiology Information Series
• Person- and Family-Centered Care
• Person-Centered Care in Audiology
• Practice Considerations for Dispensing Audiologists
• State Insurance Mandates for Hearing Aids

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Academy of Pediatrics Early Hearing Detection & Intervention Implementation Tip Sheet [PDF]
• Alexander Graham Bell Association for the Deaf & Hard of Hearing
• American Society for Deaf Children
• BEGINNINGS—For Parents of Children Who Are Deaf or Hard of Hearing
• Boys Town National Research Hospital: Parenting a Child who is Deaf or Hard of Hearing (babyhearing.org)
• Boys Town National Research Hospital: The Principles of Family-Centered Practice - Implications for Audiologists (babyhearing.org)
• Boys Town National Research Hospital: RECD Measurements (babyhearing.org)
• Centers for Disease Control and Prevention: Hearing Loss in Children
• Centers for Disease Control and Prevention: Information About Early Hearing Detection and Intervention (EHDI) State Programs
• Early Hearing Detection & Intervention: Pediatric Audiology Links to Services (EHDI-PALS)
• Educational Audiology Association
• Hands & Voices
• Hearing First
• Hearing Loss Association of America
• Hear to Learn
• Ida Institute
• Ida Institute: My Hearing Explained for Children
• Ida Institute: Tools
• Institute for Patient- and Family-Centered Care
• Joint Committee on Infant Hearing (JCIH)
• Laurent Clerc National Deaf Education Center
• National Center for Hearing Assessment and Management (NCHAM)
• National Center for Hearing Assessment and Management (NCHAM): Contacts for Early Hearing Detection & Intervention
• National Center for Hearing Assessment and Management (NCHAM): Family Support and Partnership
• National Center for Hearing Assessment and Management (NCHAM): State Profiles
• National Institute on Deafness and Other Communication Disorders (NIDCD)
• Outcomes of Children with Hearing Loss Study
• Supporting Success For Children with Hearing Loss
  • FM Systems
  • Personal FM vs Sound Field FM (Classroom Audio Distribution System)
  • Strategies for Keeping Hearing Aids on Young Children
• The University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP)
• U.S. Department of Education: Early Intervention Program for Infants and Toddlers with Disabilities
• U.S. Department of Education: Protecting Students With Disabilities (FAQs About Section 504)
• U.S. Food & Drug Administration: How to get Hearing Aids
• World Health Organization: International Classification of Functioning, Disability and Health (ICF)

Abrams, H. B., & Kihm, J. (2015). An introduction to MarkeTrak IX: A new baseline for the hearing aid market. The Hearing Review, 22(6), 16.

American National Standards Institute. (2014). Specification of hearing aid characteristics (Rev. ed.; ANSI S3.22-2014). Acoustical Society of America.

American Speech-Language-Hearing Association. (2001). Knowledge and skills required for the practice of audiologic/aural rehabilitation [Knowledge and skills]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of practice]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. https://www.asha.org/policy/

Centers for Disease Control and Prevention. (2021). Summary of 2019 national CDC EHDI data. https://www.cdc.gov/ncbddd/hearingloss/2019-data/documents/01-2019-HSFS-Data-Summary-h.pdf [PDF]

American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://www.asha.org/policy/

Chasin, M. (2011). Setting hearing aids differently for different languages. Seminars in Hearing, 32(2), 182–188. https://doi.org/10.1055/s-0031-1277240

Early Intervention Program for Infants and Toddlers With Disabilities; Assistance to States for the Education of Children With Disabilities; Final Rule and Proposed Rule, 76 F.R. 60139 (proposed September 28, 2011) (to be codified at 34 C.F.R. § 303). https://www.govinfo.gov/content/pkg/FR-2011-09-28/pdf/2011-22783.pdf [PDF]

Halpin, K. S., Smith, K. Y., Widen, J. E., & Chertoff, M. E. (2010). Effects of universal newborn hearing screening on an early intervention program for children with hearing loss, birth to 3 yr of age. Journal of the American Academy of Audiology, 21(3), 169–175. https://doi.org/10.3766/jaaa.21.3.5

Hearing Aid Devices; Conditions for Sale, 21 C.F.R. § 801.421 (2020). https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-801/subpart-H/section-801.421

Hearing Aid Devices; Professional and Patient Labeling, 21 C.F.R. § 801.420 (2020). https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-801/subpart-H/section-801.420

Joint Committee on Infant Hearing. (2019). Year 2019 position statement: Principles and guidelines for early hearing detection and intervention programs. Journal of Early Hearing Detection and Intervention, 4(2), 1–44. https://doi.org/10.15142/fptk-b748

Keidser, G., Dillon, H., Flax, M., Ching, T., & Brewer, S. (2011). The NAL-NL2 prescription procedure. Audiology Research, 1(1), 88–90.

McCreery, R. (2011). Pediatric hearing aid fittings: Selection and verification of features. AudiologyOnline. https://www.audiologyonline.com/articles/pediatric-hearing-aid-fittings-selection-797

McCreery, R. (2013). Building blocks: RECD is a reasonable alternative to real-ear verification. The Hearing Journal, 66(7), 13–14. https://doi.org/10.1097/01.HJ.0000432411.23573.80

McCreery, R. W., & Walker, E. A. (2017). Pediatric amplification: Enhancing auditory access. Plural Publishing.

McCreery, R. W., Walker, E. A., Stiles, D. J., Spratford, M., Oleson, J. J., & Lewis, D. E. (2020). Audibility-based hearing aid fitting criteria for children with mild bilateral hearing loss. Language, Speech, and Hearing Services in Schools, 51(1), 55–67. https://doi.org/10.1044/2019_LSHSS-OCHL-19-0021

Moeller, M. P., Carr, G., Seaver, L., Stredler-Brown, A., & Holzinger, D. (2013). Best practices in family-centered early intervention for children who are deaf or hard of hearing: An international consensus statement. Journal of Deaf Studies and Deaf Education, 18(4), 429–445.

Mueller, H. G. (2001). Probe microphone measurements: 20 years of progress. Trends in Amplification, 5(2), 35–68. https://doi.org/10.1177/108471380100500202

Scollie, S., Glista, D., Seto, J., Dunn, A., Schuett, B., Hawkins, M., Pourmand, N., & Parsa, V. (2016). Fitting frequency-lowering signal processing applying the American Academy of Audiology Pediatric Amplification Guideline: Updates and protocols. Journal of the American Academy of Audiology, 27(3), 219–236. https://doi.org/10.3766/jaaa.15059

Scollie, S., Seewald, R., Cornelisse, L., Moodie, S., Bagatto, M., Laurnagaray, D., Beaulac, S., & Pumford, J. (2005). The Desired Sensation Level multistage input/output algorithm. Trends in Amplification, 9(4), 159–197. https://doi.org/10.1177/108471380500900403

Seewald, R., Moodie, S., Scollie, S., & Bagatto, M. (2005). The DSL method for pediatric hearing instrument fitting: Historical perspective and current issues. Trends in Amplification, 9(4), 145–157. https://doi.org/10.1177/108471380500900402

World Health Organization. (2001). International Classification of Functioning, Disability and Health.

Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Hearing Aids for Children page.

• Katie Brennan, MS, CCC-SLP
• Kathleen Colella, AuD, CCC-A
• Tommy Evans, AuD, CCC-A
• Samantha Gustafson, PhD, CCC-A
• Karen Muñoz, EdD, CCC-A
• Jennifer Smart, PhD, CCC-A
• Laura Steinmetz, AuD, CCC-A
• Amy Tyler Krings, MA, CCC-SLP
• Elizabeth Walker, PhD, CCC-A/SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association (n.d.). Hearing Aids for Children (Practice Portal). Retrieved month, day, year, from www.asha.org/practice-portal/professional-issues/hearing-aids-for-children/.